Diagnostic Laparoscopy: Finding the Cause of Pelvic Symptoms

Diagnostic Laparoscopy: Finding the Cause of Pelvic Symptoms

Diagnostic laparoscopy is a keyhole operation that lets the surgeon look directly at the uterus, tubes, ovaries and the lining of the pelvis. It can find causes of pain or infertility that scans and examination miss. It is also an operation under general anaesthetic, so current guidelines reserve it for women in whom less invasive tests have not given an answer, or who need treatment that can be done at the same time.

What diagnostic laparoscopy is

A thin telescope (laparoscope) is passed through a small cut, usually at the navel, after the abdomen has been gently inflated with gas. A camera shows the pelvis on a screen. One or two further small cuts may be made for instruments that move organs aside, take biopsies or treat small problems. Dye can be passed through the cervix at the same time to show whether the fallopian tubes are open.

The RCOG consent advice explains that the operation is used to find the cause of symptoms, though sometimes no cause is found. It is diagnostic, so on its own it is unlikely to change symptoms. Occasionally a minor procedure treats the cause at the same time, but extra procedures such as biopsy, cyst aspiration, treatment of endometriosis or division of adhesions need separate consent.

Why it is done

• Chronic pelvic pain, when history, examination and ultrasound have not explained it and other treatment has not helped.
• Suspected endometriosis, especially when imaging is normal but symptoms are significant.
• Infertility, when tubal damage, adhesions or endometriosis are suspected, for example after previous pelvic infection, ectopic pregnancy or surgery.
• Acute pelvic pain, when the cause is unclear and a surgical emergency such as ovarian torsion or appendicitis has to be excluded.
• Looking for and treating adhesions, cysts or other pelvic disease found on scans.

What the guidelines say

Body	Document	Relevant position
RCOG	Initial Management of Chronic Pelvic Pain (Green-top 41)	Laparoscopy is a second-line test, considered if other treatments fail, rather than the "gold standard" it was once seen as. It is reasonable when adhesive disease or endometriosis needing surgery is strongly suspected, or when a woman has specific concerns such as fertility. One-third to one-half of diagnostic laparoscopies are negative, and some findings may not explain the pain. Risks and the chance of a negative result should be discussed before surgery.
NICE	Endometriosis, NG73	Consider laparoscopy to diagnose endometriosis in women with suspected disease, even if ultrasound was normal. A gynaecologist trained in endometriosis surgery should inspect the pelvis systematically. Consider treating superficial peritoneal disease and uncomplicated endometriomas at the same operation. A negative biopsy does not exclude endometriosis, and a normal systematic laparoscopy means the woman does not have it. Do not use pelvic MRI as the first test.
ESHRE	Endometriosis guideline, 2022	Laparoscopy is no longer the diagnostic gold standard. It is advised mainly when imaging is negative and/or empirical treatment is ineffective or unsuitable. A Cochrane review cited in the guideline found transvaginal ultrasound and MRI useful for endometrioma and deep endometriosis, with superficial disease harder to detect without surgery.
RCOG	Consent Advice 2: Diagnostic laparoscopy	Gives the benefits and risks to be discussed before consent, including serious complications in about 2 in 1,000 women.
RCOG	Green-top 49: entry-related injuries	Describes safe entry, women at higher risk of injury, and the need to record the counselling given.

The NICE fertility guidance (NG257, which replaced CG156) was not opened for this article, so the fertility points below are stated in general terms.

Is laparoscopy always the right first test?

No. For endometriosis, both NICE and ESHRE now put ultrasound first, with MRI used to map deep disease rather than as a starting point. Symptoms can also be treated without a surgical diagnosis in many women, and ESHRE advises laparoscopy mainly when imaging is negative or treatment has not worked.

For chronic pelvic pain, the MEDAL study followed 291 UK women who had already had history, examination and ultrasound. MRI was poor at ruling out disease: its negative predictive value was 58.1%, so many women with a normal MRI would still have had findings at laparoscopy. Over half of the women (54%) had no structural cause. The researchers concluded that MRI has no routine role, and that laparoscopy was more cost-effective than MRI in this group.

The message is balanced. Laparoscopy is the most direct test for adhesions and superficial endometriosis, but it fails to find a cause in a large share of women, and a normal result is still useful information.

What to expect

1. Before. The surgeon explains why the operation is advised, what may be found and what extra procedures you consent to. Pregnancy is excluded, and you meet the anaesthetist to discuss the form of anaesthesia.
2. Entry. Under general anaesthesia, the abdomen is entered through a small cut at the navel, or sometimes elsewhere. RCOG Green-top 49 sets out techniques, and recommends extra care and an alternative entry site for women who are obese or very underweight, or who have had previous midline surgery or peritonitis. Instruments are placed under direct vision.
3. Inspection. The surgeon systematically inspects the uterus, tubes, ovaries, pelvic walls, pouch of Douglas and often the bowel surface, liver and appendix. Dye may be passed through the cervix to test tubal patency, and biopsies may be taken.
4. Treatment when agreed. If you consented to it, small problems such as superficial endometriosis, adhesions or an uncomplicated cyst may be treated at the same sitting.
5. After. Most women go home the same day. Shoulder-tip pain from the gas and soreness around the cuts are common. You should be told how to get help if problems arise.

Risks

The RCOG consent advice lists the following.

• Serious complications in about 2 in 1,000 women overall. These include damage to the bowel, bladder, uterus or major blood vessels needing immediate repair. Up to 15% of bowel injuries may not be recognised during the operation.
• Failure to get into the abdomen or to complete the planned procedure, and a hernia at the entry site.
• Death in 3 to 8 in 100,000 women, which is very rare.
• Frequent minor effects: wound bruising, shoulder-tip pain, wound gaping and wound infection.

Green-top 49 notes that reported complication rates vary with the surgeon's experience and the complexity of the operation, that previous abdominal surgery raises the risk, and that bowel injury can show itself only after discharge. Seek urgent care for increasing abdominal pain, fever, vomiting, a swollen abdomen or heavy bleeding afterwards. This is general advice; follow the instructions your own team gives you.

Understanding the result

• A cause is found: endometriosis, adhesions, a hydrosalpinx, ovarian cysts or fibroids are among the possible findings. Treatment depends on the finding, your symptoms and your plans for pregnancy.
• Nothing is found: RCOG notes that one-third to one-half of diagnostic laparoscopies are negative. NICE advises that after a full, systematic and normal laparoscopy the woman should be told she does not have endometriosis and offered other management. A normal result also rules out some serious causes.
• Findings that may not explain the pain: RCOG cautions that some pathology found is not necessarily the cause of the pain, which is why the result is discussed alongside your symptoms.

Frequently asked questions

Is diagnostic laparoscopy major surgery?

It uses small cuts and most women go home the same day, but it needs a general anaesthetic and carries the risks above, so it is not a minor procedure.

Will laparoscopy treat my pain?

According to RCOG consent advice, a diagnostic laparoscopy is unlikely to change symptoms by itself. Treatment may be done at the same time if you have agreed to it.

Can I avoid laparoscopy?

Often there are alternatives, including ultrasound, MRI for suspected deep endometriosis, and a trial of treatment. Which is suitable depends on your symptoms. Discuss the options with your gynaecologist.

What if nothing is found?

This is common, and it is still useful because it excludes several conditions. Your team can then plan other pain management; a negative result should not end the conversation about your symptoms.

Sources

This article is educational and does not replace individual medical advice. Details were taken from the pages below; some points rely on summaries, so confirm exact recommendations against the originals before clinical use.

• RCOG Consent Advice 2: Diagnostic laparoscopy
• RCOG Green-top 49: Preventing entry-related gynaecological laparoscopic injuries
• RCOG Green-top 41: The initial management of chronic pelvic pain
• NICE NG73: Endometriosis, diagnosis and management
• ESHRE guideline: Endometriosis, 2022
• NIHR Evidence: MRI does not help to find the cause of pelvic pain in women (MEDAL study)